Currently, the antibiotic era is threatened by the convergence of three adverse circumstances: high levels of antibacterial resistance among important pathogens, a dwindling supply of novel classes of antibacterials, and a dramatic reduction in the number of pharmaceutical companies engaged in the discovery and development of antibacterial agents. While 10 new classes of antibiotics were discovered from the 1930s to the 1960s, only two new classes have been approved since 1970. In addition, due to the relatively unfavorable return on investment, pharmaceutical companies have been steering away from engaging in antibiotic-drug discovery.[14, 15]
The response to the public-health crisis of antibacterial resistance could be similar to the strategies used to counter HIV. For the past 30 years, NIH-funded research has made great progress in implementing various prevention measures, including reducing the transmission rate of perinatal HIV, HIV drug development and treatment, and a potential vaccine.[16, 17] In 2009, the NIH awarded $1.302 billion in research funding for HIV/AIDS.[NIH Research Portfolio Online Reporting Tools (RePORT) http://projectreporter.nih.gov]. As a marker of NIH's HIV research success, in the U.S. in 2005, there were more deaths attributed to MRSA infections than attributable to HIV/AIDS.
The NIH is not blind to the emerging problem of antibiotic resistance, and in response created the 'antimicrobial resistance' funding category. However, the title 'antimicrobial' includes viruses and parasites as well as antibiotic-resistant bacteria. Even though funding continues to increase in the antibiotic-resistance category, we found that only half of the funding is going to antibacterial research and the large increases in funding have targeted non-bacterial pathogens. The ESCKAPE pathogens are inherently different compared to viruses such as HIV and other pathogens such as Mycobacterium tuberculosis, thus they require specific attention. From a mortality stand point, even though in the United States MRSA and HIV may be on par with each other, the research dollars invested shows a stark difference ($1,565 vs. $72,000 per death) when only considering NIAID research dollars. Considering other agency dollars, not to mention funding from pharmaceutical companies, will only widen this gap further. In order to have the hope in making the tremendous advances seen in HIV research, antibacterial research would need increased backing. Separate RCDC funding categories in "Antibacterial Resistance" and "Hospital-acquired infections" might be needed in order to highlight the need for more research dollars and attention to this ongoing crisis.
Our estimates may be limited since we only assessed NIAID funding, and not other institutes in the NIH or other agencies such as the CDC, the Agency for Healthcare Research and Quality (AHRQ), or Veteran's Health Administration. However, NIAID is the major agency within NIH that focuses on antimicrobial research. NIAID currently spends $800 million per year in antimicrobial research, which includes $200 million annually in research to better understand the causes, consequences, and treatments of drug resistance. CDC has allocated approximately $17 million for antimicrobial resistance, which is mainly for preparedness, detection, and control purposes not for research. Congress appropriated $5 million for MRSA and related hospital-associated infections in 2007-2008, then in 2009 $17 million ($8 million for MRSA and the remaining for other HAI) to AHRQ. The VHA receives approximately $500 million in medical research but most of the funding is divided among other projects such as Gulf War illnesses, genomics, prosthetics, diabetes, and heart disease. Very little is given to antimicrobial research. The combined total from these various agencies is a fraction of what the NIAID funds, thus our research is representative of the funding situation of antimicrobial research. Our data may be limited by missing information in the NIH RePORT website. However, this is the best public access source of NIAID research funding and should be up to date for FY2007-2009. Finally, our estimates of the amount of research funding spent per S. aureus or C. difficile death may be an overestimate or underestimate since we do not have mortality data from FY2009. However, the number of deaths associated with MRSA or C. difficile should not have significantly declined because no new antibiotics have become available since 2005.
In summary, although it is impressive that the funding for ESCKAPE pathogens has increased over a relatively short period of time, funding levels for antimicrobial-resistant bacteria related grants is still lower than funding for antimicrobial-resistant, non-bacteria related grants. Annual NIAID funding for MRSA and C. difficile infections remains below $2,000 per death. Steps should be made in order to match the funding for ESCKAPE pathogens to their disease burden. If we are to have any hope in holding back the tide of antibacterial resistant pathogens as a cause of community and hospital-acquired infections, it is likely that funding will have to increase to the levels successfully employed in HIV-related research during the past three decades. NIAID should be encouraged to make a clear public commitment to increasing funding for the development of new antibacterials and expand the knowledge base around infection prevention.